Discrimination/harassment Complaint Form Page 2
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5I believe I was discriminated/harassed/retaliated against by:
Name of RESPONDENT:
(If more than one respondent, list complete information for each)
Address (local):
Address (residence):
City:
State:
Zip:
Sex:
Male
Female
Phone: [work] ____________________
[home] ____________________
Status: Student
Faculty
Staff
Administrator
External/Non-Campus
Name of RESPONDENT #2:
(If more than one respondent, list complete information for each)
Address (local):
Address (residence):
City:
State:
Zip:
Sex:
Male
Female
Phone: [work] ____________________
[home] ____________________
Status:
Student
Faculty
Staff
Administrator
External/Non-Campus
Name of RESPONDENT #3:
(If more than one respondent, list complete information for each)
Address (local):
Address (residence):
City:
State:
Zip:
Sex:
Male
Female
Phone: [work] ____________________
[home] ____________________
Status:
Student
Faculty
Staff
Administrator
External/Non-Campus
2
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Parent category: Legal